Cambridgeshire and Peterborough NHS Foundation Trust to make improvements to keep people safe
The Care Quality Commission (CQC) inspected an acute ward for adults of working age and psychiatric intensive care unit at Fulbourn Hospital, Cambridge, in May.
This inspection followed information received by CQC of a patient allegedly sexually assaulting another patient at the service, which is run by Cambridgeshire and Peterborough NHS Foundation Trust.
Inspectors found that staff could not observe patients in all parts of the ward, recording of patient observations were poor, records of incidents were missing, and parts of the physical environment were unclean. As a result, CQC issued the trust a warning notice.
Separately, CQC inspected the trust’s liaison psychiatry service at Peterborough City Hospital in March. This formed part of a system-wide review into urgent and emergency care in the area covered by Cambridgeshire and Peterborough Integrated Care System.
The liaison psychiatry service is part of the trust’s mental health crisis service. It supports people presenting at Peterborough City Hospital’s emergency department with mental health needs, as well as managing inpatients’ mental health needs at the acute hospital.
Inspectors found this service was generally providing high standards of care and treatment to people.
Craig Howarth, CQC head of inspection for mental health and community health services, said:
“While both inspections identified some good practice, we had significant concerns about the safety and dignity of patients on the acute ward for adults of working age and psychiatric intensive care unit at Fulbourn Hospital.
“Patient observations were poor in this service, which in at least one case led to a patient coming to harm. We also found some areas of the premises were unacceptably dirty, which undermined people’s safety and dignity.
“Behind this was a lack of good leadership to ensure issues were identified and addressed. This includes a failure to consistently develop approaches to support patients who presented challenging behaviour.
“These issues led to us serving the trust a warning notice, so the trust now has a legal obligation make improvements.
“We found the liaison psychiatry service at Peterborough City Hospital was meeting standards people have a right to expect, and people could access it when needed.
“However, work was needed to ensure training targets were met, and better access to a psychology specialist was needed to support patients to have the best possible outcomes.
“We have communicated our inspection findings to the trust, so its leaders know where improvements are needed.
“We continue to monitor these services closely, including through future inspections and to ensure compliance with the warning notice.”
The inspection of the acute ward for adults of working age and psychiatric intensive care unit at Fulbourn Hospital found:
Staff could not observe patients in all parts of the ward due to poor lines of sight. Observation records were not completed frequently enough, and a record covering an instance of one patient inappropriately touching another had been lost. Inspectors also found a patient had been able to self-harm while supposedly under close observation.
Not all areas were clean, and one patient’s bedroom was in a very poor condition. Its floor was heavily soiled with food and drink, dirty crockery and debris were visible, and the ensuite toilet had dried faeces around the bowl and urine stains on its floor. Staff reported deciding not to clean this room due to concerns the patient would accuse them of theft, but their failure to develop an approach to intervene could be considered neglect.
Safe staffing levels and training targets were not always met.
Some staff reported feeling unvalued.
Although leaders had the skills needed to succeed, they had not ensured all necessary information was captured and used to inform their running of the service.
The inspection of liaison psychiatry service at Peterborough City Hospital found:
The service was easy to access, and patients were promptly assessed.
Staff followed good safeguarding practices.
Patients received holistic care plans, developed with their families and carers.
Staff received supervision and appraisal, and they worked well together and with relevant external organisations.
Staff training compliance was very low in some areas.
Patient risk was assessed and responded to, but there were inconsistencies in assessment and recording.
Clinical audits had not been fully reinstated following the pandemic.
There was inadequate access to the agreed psychologist specialist.
Ratings were not issued following the inspections and the trust’s overall rating remains good. This is because the inspections were undertaken to assess specific parts of wider services, so were not wide-ranging enough to update ratings.
The inspection reports will be published on CQC's website tomorrow, Friday 22 July.